April 20, 2010 -- Today the Philadelphia Inquirer ran a very good article by Stacey Burling about a new University of Pennsylvania study finding that the lives of hundreds of surgical patients could be saved if hospitals in Pennsylvania and New Jersey followed the minimum nurse staffing ratios that have been required in California since 2004. The study also found that nurses in California, where staffing was better, liked their jobs more and felt less burned out. The study was led by prominent Penn nursing scholar Linda Aiken, who has published other ground-breaking studies over the years linking improved nurse staffing to lower patient mortality and reduced nurse burnout. The article provides context about the larger implications of the study on quality of care, nurse staffing legislation pending in various states, the ongoing nursing shortage, and even the then-current strike by nurses and others at Philadelphia's Temple University Hospital, a dispute in which nurse-to-patient ratios were a major issue. The piece includes helpful quotes from Professor Aiken and the nurses' union president Patricia Eakin, as well as ratio opponents, the Temple hospital's interim CEO Sandy Gomberg (a nurse!) and New Jersey Hospital Association representative Aline Holmes. Aiken describes the other research showing that better nurse staffing improves patient outcomes, and Eakin explains specifically how under-staffing prevents nurses from giving good care. We thank Ms. Burling and the Inquirer for this helpful report on topics that are vital to nursing practice.

The piece's excellent headline captures the story: "More nurses, less death." Key findings of the study reportedly include that 10-13 percent "fewer surgical patients in New Jersey and Pennsylvania would die if hospitals in those states had as many nurses as California law requires." Specifically, the study indicates that the ratios could have saved the lives of 468 additional patients during 2005 and 2006 in the two states. Aiken, who "directs the Center for Health Outcomes and Policy Research at Penn," is quoted suggesting that better nurse staffing likely could save "many thousands a year" nationwide. The study found that the average California medical-surgical unit nurse cared for two fewer patients than the average New Jersey nurse and 1.7 fewer than the average Pennsylvania nurse. And it found that "nurses in California liked their jobs better and were less likely to feel burned out, an important finding because of the projected shortage of nurses." The piece gives background details to help readers evaluate the scope and reliability of the study. The study was published in the journal Health Services Research, and it was based on reports of deaths within 30 days after surgery in the two-year period, encompassing a total of 1.1 million patients, as well as on surveys of more than 22,000 nurses. The article might have explained exactly which type of patients the study looked at (surgical) and controls placed on the study.

Minimum nurse to patient ratio by unit type as mandated by California legislature

Medical-surgical

1:5

Pediatric

1:4

Intensive-care

1:2

Oncology

1:5

Labor/delivery

1:3

The report also gives general context. Aiken says that (in the report's words) "the new study followed decades of research showing that patient outcomes were better when nurses cared for fewer patients." Aiken decided to compare California to other states in order to underline that nurse staffing was a broader issue. The article explains that California was the first and is still the only U.S. state to implement unit-based "minimum nurse-to-patient standards," giving the examples of the one-to-five medical surgical limit and the one-to-two intensive care limit. It also includes a chart at the end of the piece showing five different ratios required in California. It's critical that the piece specifies that the ratios are minimums, because some have actually suggested that staffing ratios actually require an exact number which cannot be exceeded. But naturally, hospitals are always free to staff with more nurses if patient acuity requires that. Aiken notes that 18 different U.S. states are considering some type of nurse staffing legislation. The report says that bills in Pennsylvania "would either set minimum ratios or require hospitals to establish committees that would develop a 'safe staffing plan' for nurses," and that New Jersey already requires hospitals to report staffing ratios to the state. This gives readers some sense of the regulatory options, though more detail would have been helpful. The report might have pointed out the vast difference between actually requiring minimum ratios and simply requiring hospitals to develop a "plan," which might lead to few real changes on the ground. And the report might have mentioned other legislative options, such as mandatory disclosure of staffing information directly to health consumers.

The piece does pursue the local situation further, noting that Aiken says many Pennsylvania and New Jersey hospitals do meet the California nurse staffing standards. Aline Holmes, "senior vice president for clinical affairs for the New Jersey Hospital Association," says two-thirds of hospitals in New Jersey have medical-surgical unit nurse-to-patient ratios of 1 to 5.5 or less. Holmes also said that (in the report's words) "previous studies had not shown that California's mandates led to better patient outcomes," which is technically correct but somewhat misleading, since the fact that these specific ratios have not been studied does not mean there is no research showing that better ratios save lives. The article might have noted that Aiken herself led a ground-breaking 2000 study published in the Journal of the American Medical Association showing that post-surgical mortality increased by 31% when nurses' patient loads changed from four to eight patients. Holmes also reportedly says that "hospitals should determine staffing based on how sick patients are," which might be a suggestion that the California ratios are arbitrary numbers not based on acuity (which is incorrect), or a general argument that hospitals must have discretion to assess acuity themselves, an apparent request for trust that many nurses believe has not been earned since the start of the cost-cutting managed care era.

And bringing the importance of the study home to Philadelphia, the article notes that nurse staffing ratios are "among the issues" in the pending strike of 1,500 hospital workers at Temple. The union for the striking nurses and "allied professionals" is PASNAP, the Pennsylvania Association of Staff Nurses and Allied Professionals. PASNAP has reportedly "proposed staffing requirements similar to those in California" for Temple, though only one of the union's hospitals currently has minimum ratios in place. PASNAP president Patricia Eakin says Temple nurses have experienced staffing levels they consider unsafe. Eakin is also the source for a helpful paragraph explaining exactly what happens when nurses are under-staffed:

When nurses have to care for too many patients, they may not be able to deliver pain drugs on time or keep a close enough eye on patients with troubling symptoms, Eakin said. It can take 90 minutes to stabilize one patient whose heart stops. "Then you're
behind on everything else," she said.

The report might have linked this kind of situation to the burnout it referred to elsewhere, perhaps explaining that too many nurses have faced this situation in the past two decades, with the result that hundreds of thousands have fled the bedside at a time when even more are needed, given the aging population and advances in care technology that require more expert nursing. But this passage at least suggests why the ratios matter--nursing actually does involve important health care skills that can mean the difference between life and death.

For balance, the piece also consults Temple hospital's interim CEO Sandy Gomberg, who

said the hospital would not agree to required ratios. She said staffing was too complex - a mixture of patient needs, nurse skills, available technology, and unit geography - to reduce to one number. "Quality patient care cannot be boiled down to a math problem," said Gomberg, who is a nurse.

This is great. Here the argument against ratios is being made not just by a chief nursing officer, as is often the case, but by a hospital CEO who is also a nurse--illustrating all at once that nurses can be health care leaders at the highest levels, and that there are serious divisions within the profession regarding how to ensure safe staffing. Of course, Gomberg's actual arguments are pretty weak. Once again, the ratios do not really reduce care to "one number," they set minimum staffing ratios in order to ensure that nurses are not short-staffed to the detriment of patients. If managers can show that their units often need fewer nurses than the minimums set in the California law or proposed bills elsewhere, then they should make that argument. But hospital patients are sicker on average than they have ever been, because the cost-cutting pressures of recent years have increased the use of out-patient procedures and led hospitals to discharge patients as soon as possible--a way of avoiding paying for nursing care that patients actually need. So it seems very unlikely that a hospital could show that an ICU nurse, for example, could safely handle more than two patients today. The California ratios were not the result of some non-nurse bureaucrats making arbitrary decisions about nurse staffing; the California Nurses Association fought for them for many years. Sadly, it often seems that arguments against staffing ratios really have everything to do with cost, rather than acuity or hospital discretion. Yet there is support for the idea that better staffing can actually cut overall costs by preventing errors and complications and reducing nurse turnover. As with many other nursing problems, this one may be largely rooted in undervaluation of the profession.

At least press reports like this one, and of course the underlying Penn study, help to increase public understanding of the importance of nursing to patient outcomes.

Ten to 13 percent fewer surgical patients in New Jersey and Pennsylvania would die if hospitals in those states had as many nurses as California law requires, according to a University of Pennsylvania study published Tuesday.

The study of 1.1 million patients in 2005 and 2006 found that the nurse-to-patient ratios mandated in California could have saved the lives of 468 patients in New Jersey and Pennsylvania over a two-year period.

Linda Aiken, who led the study and directs the Center for Health Outcomes and Policy Research at Penn, said improved nurse staffing likely could save "many thousands a year" nationally.

The study was based on reports to states of deaths within 30 days of surgery and surveys completed by 22,336 nurses. It was published in the journal Health Services Research. Aiken said 18 states, including Pennsylvania, were considering legislation on nurse-staffing levels.

She decided to compare California to other states rather than look at what happened in California before and after the law so that people would see this as a broader issue. "What happens in California," she said, "is relevant for other parts of the country."

California became the first, and only, state to enforce minimum nurse-to-patient standards in 2004. For example, it says one nurse can be responsible for no more than five patients on a medical-surgical unit and two in an intensive-care unit.

Aiken's study found that, on average, nurses in California medical-surgical units cared for two fewer patients than nurses in New Jersey and 1.7 fewer than in Pennsylvania. It also found that nurses in California liked their jobs better and were less likely to feel burned out, an important finding because of the projected shortage of nurses.

Bills have been introduced in Pennsylvania that would either set minimum ratios or require hospitals to establish committees that would develop a "safe staffing plan" for nurses. New Jersey last year began requiring hospitals to report staffing ratios to the Department of Health and Senior Services.

Nurse-to-patient ratios are among the issues dividing 1,500 striking workers and their administrators at Temple University Hospital.

The strikers, who are nurses and allied professionals represented by PASNAP, the Pennsylvania Association of Staff Nurses and Allied Professionals, have proposed staffing requirements similar to those in California.

Patricia Eakin, PASNAP's president, said nurses often encountered staffing levels at Temple they considered "unsafe." The union has only one contract that includes staffing ratios, at Mercy Suburban Hospital in East Norriton.

When nurses have to care for too many patients, they may not be able to deliver pain drugs on time or keep a close enough eye on patients with troubling symptoms, Eakin said. It can take 90 minutes to stabilize one patient whose heart stops. "Then you're behind on everything else," she said.

Sandy Gomberg, interim chief executive officer at Temple, said the hospital would not agree to required ratios. She said staffing was too complex - a mixture of patient needs, nurse skills, available technology, and unit geography - to reduce to one number. "Quality patient care cannot be boiled down to a math problem," said Gomberg, who is a nurse.

Aiken said the new study followed decades of research showing that patient outcomes were better when nurses cared for fewer patients.

She said many hospitals in Pennsylvania and New Jersey already met California's nursing requirements. "Some hospitals are quite good and some hospitals really have unsafe staffing by the standards of California," she said. Her report did not identify specific hospitals.

Aline Holmes, senior vice president for clinical affairs for the New Jersey Hospital Association, said two-thirds of hospitals in New Jersey had medical-surgical unit nurse-to-patient ratios of 1 to 5.5 or less. She said previous studies had not shown that California's mandates led to better patient outcomes. She thinks hospitals should determine staffing based on how sick patients are.